Wednesday, January 23, 2008

Exposing quackery in medical education

Academic medical woo (maybe we should start calling it quackademic medicine) has, in recent weeks, received increased coverage in the blogosphere and beyond. I’m encouraged by this groundswell of interest. Medical education needs a good Flexnerian housecleaning. What better tribute could be paid to Abraham Flexner a century after his seminal report? If Flexner could see what’s happening in academic medicine today he would be appalled. He was not in sympathy with integrative medicine. Wikipedia has this to say about the impact of the Flexner Report:

Medical schools that offered training in various disciplines including eclectic medicine, physiomedicalism, naturopathy and homeopathy, were told either to drop these courses from their curriculum or lose their accreditation and underwriting support. A few schools resisted for a time, but eventually all complied with the Report or shut their doors.

Soon after the Flexner Report and for decades thereafter medical education and practice gradually became more scientific, long before Guyatt and colleagues coined the term evidence based medicine. (I reviewed some of the history of twentieth century medicine’s scientific progress in a recent post here). Ironically, in fact, it was about the time the evidence based medicine movement was birthed in 1992 that pseudoscience under the rubric of complementary and alternative medicine was getting its foot in the door of medical schools. Since then medical education has turned its back on Flexner’s warnings and devolved from its scientific underpinnings.

If there’s any chance to expunge quackery promotion from academic medicine it has to start with exposure. Recent blog and media reactions have been modestly encouraging. Here’s a roundup of the past few weeks along with some observations.

Kevin, in typical pithy style, nailed it by pointing out that the infiltration of woo is weakening the credibility of academic medicine and damaging the evidence based medicine movement. His post was titled A step backward for academic medicine. Indeed academic medicine is moving backward, but I would characterize it as more of a slide down a slippery slope, a slide that’s picking up speed.

Dr. Wallace Sampson’s richposts from the last two weeks on the new Science Based Medicine blog examine the origins and consequences of the infiltration of pseudoscience (which he, like Flexner, terms sectarianism). He cites several examples including a recent melding of pseudoscience and mainstream medicine at Harvard University and its astonishingly uncritical coverage in, of all places, Science Magazine.

Sampson documents a broad and uncritical societal acceptance of CAM at a time when a self-doubting and overly self-critical medical establishment was vulnerable, succinctly pointing out that “the press wowed and academics cowed…”

In a post yesterday Orac noted increased media attention to CAM which, unfortunately, ranges from promotional to only partially critical. The latter article, though, from U.S. News and World Report (USNWR), made this perceptive observation: “The setting for the unorthodox therapy—an academic medical center—would have been startling just five or 10 years ago.” Yes, there was a time, a decade or two ago, when the promoters of quackery would have been laughed off the podium of most medical school classrooms.

The USNWR quoted Andrew Weil as advocating an inconsistent evidentiary standard for medical claims, a “sliding scale” of evidence in which treatments with lower risk would require an easier standard of proof. Orac notes the logical extension of that argument by pointing out that true homeopathic remedies, consisting of only water, would require no proof at all. (Maybe the burden of proof would decrease in proportion to the number of dilutions of the remedy!). On its face that argument might have some appeal. After all, if it’s harmless why question it? Aside form the obvious theoretical objection (that all scientific claims should require rigorous scientific proof) there are practical consequences to that argument which become apparent on closer examination.

The article also provided examples of academic woo that even Orac wasn’t aware of. No doubt he’ll be updating his Academic Woo Aggregator soon.

Finally, let me mention (again) the latest Medscape Roundtable in which colleagues and I debated the issue of CAM teaching in medical school. This was a unique opportunity to take the issue (apologies to Dr. Anonymous) “beyond the blog” to the vast audience of Medscape.

A recurring question was raised in many of the postings: what’s driving the infusion of woo into academic medicine? One obvious factor is money. Consumer demand for woo is high and patients are willing to pay out of pocket for it. There being no scientific basis for most of these therapies, a desire to take patients’ money may be reason enough for some folks on the administrative side of academic medical institutions.

Other reasons include political correctness and postmodernism which I discussed at some length here. Wallace Sampson and Kimball Atwood IV, in a commentary in the Medical Journal of Australia, describe the effects of postmodernism with its “multiple ways of knowing” on medicine:

In the postmodern catechism, facts and science are artefacts of social constructions, and modern medicine expresses political hegemony over other, subjugated forms of healing, such as naturopathy and homoeopathy.Postmodern CAM also tolerates contradiction without need for resolution through reason and experiment, resulting in a medical pluralism. Various “schools” and philosophies of healing — each inconsistent with the others, such as chiropractic, homoeopathy, orthomolecular medicine, and traditional Chinese medicine — create a scientific multiculturalism. Implausible proposals and claims become tolerable and comfortable, and the CAM advocate’s burden of proof is shifted to disproof by the science community, which that community accepts without major objection.

Finally, and somewhat paradoxically, the rise in unfounded CAM modalities may be an unintended consequence of the EBM movement. EBM advocates devalue scientific rationale and physiologic plausibility. (That reflects a very popular distortion, not a core principle, of EBM). Again, from the Medical Journal of Australia paper:

Evidence-based medicine (EBM), relying on results of randomised trials, should be a bulwark against the Absurd. However, the heterogeneity of clinical trial methods and designs, differing population bases, and varying endpoints often result in heterogeneity of outcomes. This has precluded systematic reviews of CAM methods from defining a line of inefficacy. EBM also does not include plausibility or consistency with basic science in its methods and reviews, leaving each to physician and patient interpretation.

In another editorial Dr. Sampson further laments the distortion of EBM leading to uncritical acceptance of implausible research claims:

The second is a paradoxical consequence of "evidence-based medicine" (EBM). EBM, in the form of RCTs and their systematic reviews (SRs), is a means for accumulating and ranking data. EBM is not a means for interpreting the significance of the data. Significance depends in part on plausibility. EBM is independent of physiology and ignores plausibility.

Plausibility depends on prior reliable observations, physical and chemical laws, pharmacological principles, and advocates' economic and legal misadventures. TheNational Center for Complementary and Alternative Medicine spends $100 million/year on implausible research and training grants. In performing RCTs on implausible proposals, clinical research has taken a wrong turn and departed from rationality.

So where’s it all going? Are medical schools really becoming Hogwarts schools of witchcraft and wizardry? Maybe so! If we’re not there yet we’re headed there with increasing velocity. The boosters of CAM education are organized. Many academic medical centers have formed a Consortium for Integrative Medicine. The Consortium is supported by big money and seeks to promote integrative medicine. A careful reading of the pages of their website suggests an agenda for medical education based on experiential and promotional learning rather than critical analysis.

What can be done about it? Although the rising chorus of voices against pseudoscientific medical education is encouraging the chorus is small, and the situation, from where I sit, is not good. At this late point nothing short of all out war on quackademic medicine will be effective. It can be done. It’s not unprecedented. Just look at the lobby against deceptive pharmaceutical company marketing. They have web sites. They’re making documentary films. They’re writing books. They have visibility. We need to be similarly organized.

7 comments:

I am horrified by the mainstream academic acceptance and pandering to the politically correct "complementary & alternative medicine." Having been far away from academics over the past 20 years, I just can't believe such prominent institutions have sold out. This is all just so much superstition. When people say it would't be so popular if it didn't work, well, I daresay none of the world's religions "work" either, but that doesn't stop the believers waiting for god to cure grandma's renal failure, or from believing one or the other god has a reason in his "plan" for the toddler dying of neuroblastoma. I just don't get it. Not at all.

A recurring question was raised in many of the postings: what’s driving the infusion of woo into academic medicine? One obvious factor is money. Consumer demand for woo is high and patients are willing to pay out of pocket for it.

Indeed, while consumers gladly pay out-of-pocket for these services I am hard-pressed to identify an academic CAM center that is actually making money. The WSJ did a story about this a year or two back (and I cannot find it in the archives) saying that of the top 10 academic CAM centers, only one is in the black.

Given that CAM providers have to spend an hour or more with each consumer (note that I do not say "patient"), there's no way these centers can be profitable when the rest of the docs are required to see pts every 7 to 15 min.

Philanthropy has been taking up the slack for most of these centers but that will only last so long. Even NCCAM grants will only go so far in keeping these centers alive and I'd suspect we'll see some closing in the next 3-5 yrs due to Darwinian economics.

A very convincing and powerful description of the problem. I am a Melbourne-based education consultant and the same sickness pervades our education system in the school curriculum. Postmodern theory rules and Western science is considered simply one science among many. Following is an extract from an artcile I wrote on the problem:

One of the defining characteristics of outcomes based education is that learning is no longer based on the traditional disciplines associated with an academic curriculum and the belief that knowledge is impartial and objective.

As noted by the South Australian academic, James Gibbons in his book On Reflection, much of Australia’s school curriculum adopts a relativistic view where science, instead of being based on an objective view of reality, is considered subjective and culturally determined.

The South Australian curriculum states: “Viewing experiences, ideas and phenomena through the lenses of diverse cultural sciences provide a breadth and depth of understanding that is not possible from any one cultural perspective”.

“Every culture has its own ways of thinking and its own world views to inform its science. Western science is the most dominant form of science but it is only one form among the sciences of the world”.

The Northern Territory science curriculum adopts a similar approach; described as a “social-constructivist perspective” and one where “science as a way of knowing is constructed in a socio-cultural context”.

While the more traditional view of science is based on the belief that there are some absolutes that can be empirically tested, water boils at a certain temperature, the air we breathe is constituted a particular way, the Western Australian curriculum also argues that our understanding of the world is subjective and culturally determined:

“people from different backgrounds and cultures have different ways of experiencing and interpreting their environment, so there is a diversity of world views associated with science and scientific knowledge which should be welcomed, valued and respected”.

“They (students) appreciate that when they make observations, they do so from their own point of view and way of thinking. They recognise that aspects of scientific knowledge are constructed from a particular gender or cultural perspective”.

"Philanthropy has been taking up the slack for most of these centers but that will only last so long. Even NCCAM grants will only go so far in keeping these centers alive and I'd suspect we'll see some closing in the next 3-5 yrs due to Darwinian economics."

We can only hope you're right. I'd love to start removing entries from my Academic Woo Aggregator. I do note that the web pages for the University of Wisconsin's CAM program, although still showing up on searches on the university website, seem not to be there any longer. I don't know if that means the UW CAM program is no more, but we can hope.

When I entered medical school in 1989 I was disturbed by the lack of rigor in the scientific background of the entrants as a whole. It does not surprise me that this intellectual drift has progressed to the brink. I was in mainly outpatient medicine for several years but became so bored by the patient's obsession with trivial complaints (i.e. onychomycosis or alopecia) at the expense of serious pathology (e.g. the ever burgeoning waistline in the face of climbing HgbA1C) that I went into hospital medicine. There is zero woo in the acute care setting. The naturopath that advises the patient with severe hypertension to discontinue antihypertensive medications is nowhere to be found when a hemorrhagic stroke results. I perceive the patient's turn to such nonsense as magical thinking; a vain attempt to assert control over their illnesses. I still spend considerable time at the bedside teaching patients about the pathophysiology of their illnesses in the hope of providing them with useful tools towards health. I am not optimistic about the medical education of the future.

There being no scientific basis for most of these therapies, a desire to take patients’ money may be reason enough for some folks on the administrative side of academic medical institutions.

This. No educational institutions are free from political pressure towards commercialization, adoption of practices transplanted from business. "We're going to clear out the cobwebs, we're going to run this efficiently and rationally as a business, and that means giving our customers what they want!"

I suspect postmodernism more as a justification for this trend, rather than the cause of it. In general I'm sceptical of those branches of humanoira to cause much change.

Of irrational fear of corporations, I kind of disagree. Following the global warming debate, I would rather say most people aren't nearly afraid enough of what institutionalized corporate interests are capable of. CAM fans' error lies not so much in being suspicious of big pharmaceutical companies, but in failing to spot the huge, cutthroat industry that promote the "alternatives" (including the many pharmaceutical companies who play both sides of the table).

In short, I feel that the danger from the "left" (postmodernism, anti-corporatism, tree-hugging hippies) is a great deal overestimated compared to the danger from the "right" (corporatization of academia, corruption, vitamin-pill mercenaries).